India must overhaul medical training to act on antimicrobial resistanceBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4230 (Published 03 July 2013) Cite this as: BMJ 2013;347:f4230
- Abdul Ghafur, consultant in infectious diseases, Apollo Hospital, Chennai, India
High rates of antimicrobial resistance; a lack of functioning policy for antibiotic use; inadequate infrastructure for infection control in many hospitals; and a scarcity of infectious disease specialists: what else do you need for bugs to flourish?
These conditions apply in most countries of the Indian subcontinent. The region has never considered antibiotic resistance a menace serious enough to warrant investment. The burden of malaria, tuberculosis, typhoid, and others was enough to preoccupy Indian healthcare professionals. Hospital acquired infections have been considered primarily to be a problem for, and a preoccupation of, well resourced countries, perhaps leading to neglect of the impact of these infections.
What we forget is that India has an unusual blend of richness and poverty. This leads to wide variation for different segments of the population in access to the high quality hospitals that support the required infrastructure for good infection control and antibiotic stewardship. Additionally, although the Indian drug industry represents world class manufacturing, its emphasis on the production and sale of existing or new antibiotics fails to encourage an awareness of this public health emergency among doctors and the public. This disparity in healthcare and economic status means that antibiotic overuse co-exists with underuse and non-availability of antibiotics.
The Indian Ministry of Health is preparing an antibiotic policy incorporating the recommendations of the Chennai Declaration.1 2 Let us hope that this policy leads to the sensible use of antibiotics in hospitals and reduces non-prescription sales of them over the counter.
Treating bacterial infections without effective antibiotics is like going to a battle without weaponry. Managing serious infection without the support of infection specialists is venturing into a war without cavalry. You might think that in a country with a population of more than a billion; with tens of thousands of hospitals of varying standards; with heterogeneous healthcare delivery; and with tropical infections the bread and butter of general practitioners and physicians, that infectious diseases would be a popular medical specialty.1 Unfortunately, fewer than two dozen doctors practise infectious diseases as their primary specialty. Brazil, which faces similar challenges to India but with one fifth its population, boasts more than 1000 infectious disease specialists.
India has the advantage of a large healthcare workforce and skilled microbiologists, who have compensated for this deficiency to a degree. However, training of microbiologists in India is very much laboratory oriented at undergraduate and postgraduate levels, with inadequate emphasis on prescribing antibiotics and infection control. Such a biased curriculum deters prospective candidates from this important specialty.
The medical curriculum in India is old fashioned, with trainee doctors compelled to read many textbooks primarily meant for an audience of postgraduate doctors and specialists. A strong theoretical background might seem an advantage, but in reality trainees lose precious time that they could have spent acquiring the clinical skills necessary for day to day practice. The examination system in India for undergraduate and postgraduate trainees is largely based on subjective parameters rather than the objective measures used in most developed countries. Examiners are keener to assess knowledge of clinical signs of historic importance that doctors no longer use.
We must modernise our medical curriculum to emphasise diseases encountered in the tropics. Training on rational antibiotic use and infection control should be integral for undergraduates and postgraduate trainees. Postdoctoral training in infectious diseases must be initiated in all major teaching hospitals. Microbiologists must receive training in infection control and antibiotic stewardship.
The curriculum should be remodelled to include more clinically oriented basic science training, rather than making students spend a year and a half of their academic life learning unnecessary details of preclinical subjects. Clinical training should use real life scenarios, preparing trainees for the day to day problems they will encounter, instead of spoon feeding them with information about diseases of historical significance.
The Medical Council of India and the equivalent bodies in neighbouring countries urgently need to rectify the serious defects in training and examination in the medical curriculum.
Cite this as: BMJ 2013;347:f4230
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.